Healthcare Provider Details

I. General information

NPI: 1871963199
Provider Name (Legal Business Name): EVELYN LOUIS HAACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2015
Last Update Date: 09/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 SAINT ANDREW ST STE 100
LA CROSSE WI
54603-2378
US

IV. Provider business mailing address

W6774 STRAWBERRY RD
ONALASKA WI
54650-9232
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-6266
  • Fax:
Mailing address:
  • Phone: 608-783-1167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number134350
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: